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Maria Ford

plcIndications

1.1Background

The Intra-Aortic Balloon Pump (IABP) is a circulatory assist device that is used to support the left ventricle. It is used in patients with a wide range of disorders that cause a low cardiac output and include:

Haemodynamic support during and after Percutaneous Coronary Intervention (PCI)

Unstable angina

Cardiogenic shock

Pre operatively in high risk patients

Mechanical complications post myocardial infarction

The IABP is inserted percutaneously through the femoral artery and positioned in the descending thoracic aorta. The catheter tip lies distal to the left subclavian artery and proximal to the renal arteries. On chest x-ray, the tip should be visible between the 2nd and 3rd intercostal space.

Figure 1: Balloon pump set up

The size of the IABP is dependent on patient’s height to prevent occlusion of the renal and subclavian arteries. Inflation and deflation of the balloon catheter is timed to the cardiac cycle.The balloon is connected to a console that regulates the inflation or deflation of the balloon with the passage of helium. Inflation of IABP occurs just after the closure of the aortic valve causing an increase in diastolic arterial pressure and an increase in cardiac output.

Figure 2: Balloon inflation

Deflation of the IABP occurs in systole causing a decrease in aortic end diastolic pressure, ventricle wall tension and increase in stroke volume.

Figure 3: Balloon deflation

The physiological effects are:

Increases coronary artery perfusion

Increases myocardial oxygen supply

Decreases myocardial oxygen demand

Decreases myocardial work by reducing afterload

Increases blood pressure

Decreases pulmonary artery pressure

Helium is used to inflate the balloon as it is easily dissolved in blood and prevents the risk of air emboli if the catheter ruptures. When a patient is on an intra-aortic balloon pump the nurse should expect to see the following waveform, figure 4.

Figure 4: Normal balloon inflation

When balloon-assisted, the diastolic pressure should always be the highest pressure recorded on the waveform. This will ensure that the coronary arteries receive the maximum blood flow. The balloon-assisted systolic pressure should be lower than the patients non-assisted, systolic pressure due to the reduction in afterload.

Arterial pressure monitoring

The central lumen of the IABP catheter allows monitoring of the arterial pressure in the descending aorta during the cardiac cycle. When connected to a transducer it will display a waveform that the nurse will be expected to interpret.

For further information about care of the arterial line please refer to the “Arterial Line Policy”.

IABP triggering

The trigger is the way the IABP identifies the beginning of the cardiac cycle. There are 5 ways triggering may be achieved.

ECG mode: Using the R wave on the ECG

Pressure: Using the arterial pressure waveform. In irregular rhythms, the pressure trigger mode is not recommended

Pacer V (ventricular)/AV(atrioventricular): Uses ventricular spike to trigger an event, is not an appropriate trigger for demand pacing

Pacer A (atrial): Used when the patient has an atrial pacemaker. In this mode the R wave on the ECG is the trigger, the atrial pacer spikes are enhanced and rejected. Never used for patients who have a ventricular pacemaker.

Internal: Allows a synchronous trigger set at 80 beats/min. The internal mode should never be used if a patient is generating a cardiac output.

1.2 Aim/purpose

The aim of the policy is to ensure that safe and effective care is delivered to patients who have an intra-aortic balloon pump. This will be achieved by:

Ensuring that appropriate training is provided for all personnel involved in the management of the IABP

Ensuring that the device is managed and removed safely in accordance with evidenced based practice

To ensure that practice is audited across the Trust and that local incident data relating to IABP’s are collected & reviewed.

1.3 Patient/client group

All patients who have an intra-aortic balloon pump.

1.4 Exceptions/ contraindications

Severe aortic regurgitation

Abdominal or aortic aneurysm

Aortic dissection

Severe calcific aorta-iliac disease

Severe peripheral vascular disease

Previous fem-pop bypass

1.5 Definition of terms

Afterload

The amount of pressure the left ventricle must work against to pump blood into the systemic circulation

Preload

This is determined by the amount of blood remaining in the left ventricle at the end of diastole

Augmentation

The ability of the balloon to be fully expand and contain the full amount of helium for the catheter. During normal pumping this is maintained on full to prevent blood clots forming.

Counter pulsation

Counter pulsation is when aortic blood is displaced with the inflation and deflation of the balloon catheter. This is timed to the cardiac cycle.

Dicrotic notch

The dicrotic notch reflects the slight backflow of blood in the aorta that follows closure of the aortic valve and pulmonary valve (semi lunar). It represents the end of ventricular systole and beginning of diastole.

Contractility

The ability of the cardiac cells to contract. This depends upon how much the muscle fibres are stretched at the end of diastole

plcClinicalMangement

2.1 Staff & equipment

Staff Training

All patients with IABP’s should be cared for in clinical areas that are familiar with the needs of the patient. Nursing staff caring for these patients must have received training and be able to demonstrate that they are competent in the management of the patient. Documentation of level of competency in relation to IABP’s should be included in all ward/unit induction programs and staff training portfolios.

The practitioner must be supported to complete the ABG competency, appendix 2

The practitioner must be supported to complete the IABP competency, appendix 3

The practitioner must have received training from the cardiology physiologist and/or company representative in the care of the patient with an IABP

Ward location

Following insertion the patient will be transferred to a level 2 facility where a minimum 1 to 2 nurse to patient ratio can be secured. The Department of Health guidelines (2000) define level 2 as:

“Patients requiring more detailed observation or intervention, including support for a single failing organ system or post-operative care and those ‘stepping down’ from higher levels of care.”

Tisbury Ward and Radnor Ward are able to provide level 2 care.

The Department of Health guidelines (2000) define level 3 as:

“Patients requiring advanced respiratory support alone or basic respiratory support, together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.”

Radnor Ward is the designated level 3 facility within the Trust and will accept patient’s with an IABP who require ventilation.

Staffing levels

The patient requiring an IABP to support cardiac function may also have multisystem instability and/or failure. The intensive nature of the nursing intervention therefore requires:

The nurse to patient ratio for a patient with an IABP is 1:1

A ratio of 2:1 may be required at the discretion of the charge nurse

The nurse caring for the patient must have completed the requisite training and be able to safely manage the patient and troubleshoot the console

The nurse assigned to relieve for breaks must be trained to care for the patient on the IABP

The nurse who relieves for meal breaks must have completed the requisite training and be able to safely manage and troubleshoot the console in the nurse's absence